ACR Bulletin

Covering topics relevant to the practice of radiology

Getting Back to Basics

Applying the AUC in a CDS program is necessary and worthwhile.
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Radiology becomes part of the solution, instead of being viewed as the cause of rising healthcare spending.

—Ezequiel Silva III, MD, FACR
November 15, 2018

When PAMA passed at the end of 2014, it mandated a simple idea — at the point of ordering, referring providers must make sure the study is appropriate. Since then, translating this simple idea into reality has become far more complex than necessary. Hundreds of pages of regulatory language, and a surprisingly high degree of resistance from the rest of the medical community, have contributed to that complexity. The result has been a delayed implementation schedule, overly complicated reporting requirements, and a disappointing opposition letter from non-radiology stakeholders.

Against this backdrop, let’s return to basics and revisit the reasons why the ACR believed then, and continues to believe now, that the application of Appropriate Use Criteria (AUC) in a clinical decision support (CDS) program is worthwhile.

Radiology becomes part of the solution, instead of being viewed as the cause of rising healthcare spending.

Policymakers are committed to reducing government spending on healthcare. Current spending trends are not sustainable, which means that the search for savings is widespread.

Of course, one way to spend less is to pay less by cutting payments to providers. Radiology has certainly had its share of payment cuts. Repeatedly, imaging has been used as a “pay for,” to enable other government initiatives or just to support other federal programs outside of medicine. Beyond the financial consequences of such action, the threats to patient access, quality of care, and innovation are real.

Amid these challenges, we wondered, could we find a more constructive solution? Was there a way to shift radiology from being viewed as part of the problem to part of the solution? Could more appropriate studies, lower radiation, less waste, better outcomes, and, yes, savings, be part of that solution? Implementing CDS powered by the AUC was the answer. Being viewed as part of the solution was a way to avoid more targeted payment cuts. It was a win-win.

The alternative to CDS was pre-authorization.

Several presidents’ budgets, including President Obama’s in 2010, sought pre-authorization for imaging studies across the Medicare program. Retroactive review by non-radiologists, or even non-physicians, was not — and is not — the best option for patient care. And, ironically, many pre-authorization programs use AUC to inform their actions and denials. Why not apply those AUC prospectively and constructively, achieving physician and patient education and engagement along the way? Think about it — do physicians want their patients calling them and saying, “You know that study you ordered? The government says it is inappropriate.” Wouldn’t physicians rather hear, “Thank you for including me in the decisions regarding the best exam for me. This decision tool is helpful.”

Lawmakers will find cost-savings somewhere, and CDS presents a radiology-friendly, patient-focused option.

The Medicare program faces enormous funding challenges. Policymakers will find savings somehow, and proposals to move from volume to value will take years to mature.

However, the urgency is not going away. Provider cuts and imaging pre-authorization programs do yield savings but are not optimal for radiology or patient care. We can resist these detrimental policy changes through our talking points to policymakers, but actions in the form of a credible alternate solution are more effective. CDS is that solution.

In fact, a recent report found that the overall budgetary impact on Medicare would be a 2 to 3 percent decrease in total Medicare imaging-spending.

The current state of PAMA implementation is less than ideal, but there is reason for optimism. The voluntary CDS reporting period is underway, and a more active testing period begins in 2020. Full implementation is expected by 2021. I hope that revisiting three basic benefits of the program (better patient care, healthcare savings, and avoiding pre-authorization) reinforces our collective motivation to advance the program. If efforts to implement CDS fail, we will not like the alternatives.

Author Ezequiel Silva III, MD, FACR  Chair of the Commission on Economics